Integrated care

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In many countries of the industrialised world, healthcare
systems are faced with a common challenge for the future. An ageing population
implies an increase in the number of elderly people with several complex,
chronic conditions. An appropriate answer to this new generation of elderly is
integrated care that provides a broad spectrum of comprehensive, tailor-made
health care and social services in institutions and in the community at large
(1).

Definition
of Integrated Care and Application at Hospital Level

It
is care which appears seamless to the service recipients and which is devoid of
overlaps or gaps to service commissioners and providers. Both across and within
countries, integrated care appears in a variety of forms: ‘shared care’,
‘continued care’, ‘disease management’, ‘transmural care’, ‘comprehensive care’
and so on. These forms have in common that they are aimed at creating a
coherent and coordinated set of services which are planned, managed, and
delivered to individual service users across a range of organisations and by a
range of cooperating professionals and informal carers (1). By engaging in
integrated care arrangements, (university) hospitals create synergistic
relationships that should secure their (academic) ambitions for the future (2).
This may be all the more important for the position of hospitals in healthcare
systems which have implemented regulated competition between care providers.

Challenges
of Integrated Care

As
a consequence, the challenge of integrated care is increasingly recognised. For
example, it has been reported that in the Netherlands, general hospitals are
involved in six integrated care arrangements on average, with a maximum of
twenty initiatives. And of the eight university hospitals, three have been
reported to be working on community-based integrated care arrangements.
However, securing integrated care is complex as integration requires interorganisational
and interprofessional relationships across sectors: public; private; voluntary;
service areas (health, social care, housing, transport, education); levels of
government and different models of governance.

One
also has to take into account legislative frameworks, organisational
arrangements, competencies of providers and issues of funding .

At
a more aggregate level, three broad categories of factors can impede the
creation of integrated care arrangements. These are financial barriers,
organisational divides and ‘cultural’ differences between care providers or
institutions (3). The remainder of this article will address financial barriers,
and how to overcome them, focusing on the role of hospitals.

Financial
Barriers for Integrated Care Arrangements

As
recently illustrated in a contribution to this journal (4), financial barriers
or problems may arise at one or a combination of stages in the development of
integrated care arrangements (5):

1.
At the time of the planning and running of a preparatory or pilot project. If a
new care arrangement results in new types of provision of care or new types of
consultations it is important to include the associated costs in the budget for
the project. If such new forms of care cannot be sufficiently covered by e.g.
local insurance companies, this may result in budget deficits while the project
is ongoing.

2.
After completion of the initial project, pertaining to the financing of its
permanent continuation as a regular care provision. Already at the time of
initiating the (pilot) project, the possibilities for permanent financing need
to be addressed in case the project turns out to be successful, otherwise the arrangement
may be short-lived. For example, perhaps changes in a DRG (diagnosis-related group)
or DTC (diagnosis-treatment combination) are needed, or changes in existing
fees or an entirely new fee for a new service is needed. Of course, there is
also a possibility that no changes at all need to be made, e.g. in case the project
results in cost-savings. Ideally, at the time of decision-making relevant
information is available.

3.
After completion of the initial project, pertaining to the budgetary or general
financial consequences to particular categories of care providers involved, or
of a certain specialty. Integrated care arrangements may often have
implications for patient flows in the health care systems. Changes (reductions)
in numbers of patients may result in changes in income, which may result in
particular groups of professionals opting out. Ideally, the financial
consequences of the arrangement for all stakeholders is documented at the time
of decision-making.

Expectations
and evidence of effectiveness, cost-effectiveness and budget impact of
integrated care arrangements It is often
assumed that integrated care results inincreased effectiveness and quality of
care, whilebeing
cost-effective or even cost-saving at the sametime. Although many authors agree that
integratedcare
holds great promise, they warn against expectationsthat
may be unrealistic, while supportingan evaluative approach. When searching
the majorelectronic
databases, such as Medline and Embase,it shows that relatively few studies
have been carried out to date. Furthermore, the results of studies can often
not be directly extrapolated to other settings. It can therefore be said that
there is a need for evaluation in general, and a need for economic evaluation
in particular as, as outlined above, and perhaps due to the relative immaturity
of the field, many integrated care programmes are short-lived after initial
funding by temporary subsidies and grants at either local or national levels
runs out. A positive decision on long-term financing or reimbursement of
services can be facilitated by a timely and high-quality economic evaluation
demonstrating ‘value for money’ of the programme in question (see ref. 6).
Likewise, an economic evaluation combined with a budget impact analysis could
support decision-making on permanent reallocation of some share of, for
example, existing hospital and/or home care budget on behalf of an integrated
care arrangement, thus contributing to its long-term survival.

Conclusion

In
summary, it is recommended to start projects aimed at the development of
integrated care arrangements on the basis of careful financial planning right
from the start. Analytical tools that may prove to be extremely helpful include
the techniques of economic evaluation of healthcare programmes and budget
impact analysis. If such research is carried out alongside the pilot project the
results may contribute to a timely input to arrive at an informed decision on
the future of the arrangement when the initial project has finished.

Integrated
care is part of the redesign of healthcare systems, aimed at reflecting the
needs of an ageing population and a change to the traditional ways of providing
care. This is not only communicated by patients but is also high on the agenda
of policymakers in the developed world. Healthcare systems of the future are
likely to reflect moves away from services geared to acute episodes of care and
towards self-care and co-production of health. And healthcare systems of the
future are likely to be characterised by a redistribution of work and the
creation of new types of healthcare workers (7). If hospitals adopt a
pro-active approach to the challenge created by these anticipated changes, e.g.
by engaging in integrated care arrangements, the rewards will be many. Perhaps
more importantly, hospitals, by taking the lead in reorganising the healthcare system
they are part of, will secure their relevance in treatment of future
generations of patients.

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